Definition
Pneumonia is an inflammation of the lung parenchyma, associated with alveolar edema and congestion that impair gas exchange.
Nursing Priorities
- Maintain/improve respiratory function.
- Prevent complications.
- Support recuperative process.
- Provide information about disease process, prognosis and treatment.
Discharge Goals
- Ventilation and oxygenation adequate for individual needs.
- Complications prevented/minimized.
- Disease process/prognosis and therapeutic regimen understood.
- Lifestyle changes identified/initiated to prevent recurrence.
- Plan in place to meet needs after discharge.
Diagnostic Studies
- Chest x-ray: Identifies structural distribution (e.g., lobar, bronchial); may also reveal multiple abscesses/infiltrates, empyema (staphylococcus); scattered or localized infiltration (bacterial); or diffuse/extensive nodular infiltrates (more often viral). In mycoplasmal pneumonia, chest x-ray may be clear.
- Fiberoptic bronchoscopy: May be both diagnostic (qualitative cultures) and therapeutic (re-expansion of lung segment).
- ABGs/pulse oximetry: Abnormalities may be present, depending on extent of lung involvement and underlying lung disease.
- Gram stain/cultures: Sputum collection; needle aspiration of empyema, pleural, and transtracheal or transthoracic fluids; lung biopsies and blood cultures may be done to recover causative organism. More than one type of organism may be present; common bacteria include Diplococcus pneumoniae, Staphylococcus aureus, a-hemolytic streptococcus, Haemophilus influenzae; cytomegalovirus (CMV). Note: Sputum cultures may not identify all offending organisms. Blood cultures may show transient bacteremia.
- CBC: Leukocytosis usually present, although a low white blood cell (WBC) count may be present in viral infection, immunosuppressed conditions such as AIDS, and overwhelming bacterial pneumonia. Erythrocyte sedimentation rate (ESR) is elevated.
- Serologic studies, e.g., viral or Legionella titers, cold agglutinins: Assist in differential diagnosis of specific organism.
- Pulmonary function studies: Volumes may be decreased (congestion and alveolar collapse); airway pressure may be increased and compliance decreased. Shunting is present (hypoxemia).
- Electrolytes: Sodium and chloride levels may be low.
- Bilirubin: May be increased.
- Percutaneous aspiration/open biopsy of lung tissues: May reveal typical intranuclear and cytoplasmic inclusions (CMV), characteristic giant cells (rubeola).
Nursing Care plans
Below are 8 Nursing Care Plans (NCP) for Pneumonia.
Ineffective Airway Clearance
Nursing Diagnosis: Airway Clearance, ineffective
May be related to
- Tracheal bronchial inflammation, edema formation, increased sputum production
- Pleuritic pain
- Decreased energy, fatigue
Possibly evidenced by
- Changes in rate, depth of respirations
- Abnormal breath sounds, use of accessory muscles
- Dyspnea, cyanosis
- Cough, effective or ineffective; with/without sputum production
Desired Outcomes
- Identify/demonstrate behaviors to achieve airway clearance.
- Display patent airway with breath sounds clearing; absence of dyspnea, cyanosis.
| Nursing Interventions | Rationale |
| Assess rate/depth of respirations and chest movement. | Tachypnea, shallow respirations, and asymmetric chest movement are frequently present because of discomfort of moving chest wall and/or fluid in lung. |
| Auscultate lung fields, noting areas of decreased/absent airflow and adventitious breath sounds, e.g., crackles, wheezes. | Decreased airflow occurs in areas consolidated with fluid. Bronchial breath sounds (normal over bronchus) can also occur in consolidated areas. Crackles, rhonchi, and wheezes are heard on inspiration and/or expiration in response to fluid accumulation, thick secretions, and airway spasm/obstruction. |
| Elevate head of bed, change position frequently. | Lowers diaphragm, promoting chest expansion, aeration of lung segments, mobilization and expectoration of secretions. |
| Assist patient with frequent deep-breathing exercises. Demonstrate/help patient learn to perform activity, e.g., splinting chest and effective coughing while in upright position. | Deep breathing facilitates maximum expansion of the lungs/smaller airways. Coughing is a natural self-cleaning mechanism, assisting the cilia to maintain patent airways. Splinting reduces chest discomfort, and an upright position favors deeper, more forceful cough effort. |
| Suction as indicated (e.g., frequent or sustained cough, adventitious breath sounds, desaturation related to airway secretions). | Stimulates cough or mechanically clears airway in patient who is unable to do so because of ineffective cough or decreased level of consciousness. |
| Force fluids to at least 3000 mL/day (unless contraindicated, as in heart failure). Offer warm, rather than cold, fluids. | Fluids (especially warm liquids) aid in mobilization and expectoration of secretions. |
| Assist with/monitor effects of nebulizer treatments and other respiratory physiotherapy, e.g., incentive spirometer, IPPB, percussion, postural drainage. Perform treatments between meals and limit fluids when appropriate. | Facilitates liquefaction and removal of secretions. Postural drainage may not be effective in interstitial pneumonias or those causing alveolar exudate/destruction. Coordination of treatments/schedules and oral intake reduces likelihood of vomiting with coughing, expectorations. |
| Administer medications as indicated: mucolytics, expectorants, bronchodilators, analgesics. | Aids in reduction of bronchospasm and mobilization of secretions. Analgesics are given to improve cough effort by reducing discomfort, but should be used cautiously because they can decrease cough effort/depress respirations. |
| Provide supplemental fluids, e.g., IV, humidified oxygen, and room humidification. | Fluids are required to replace losses (including insensible) and aid in mobilization of secretions. Note: Some studies indicate that room humidification has been found to provide minimal benefit and is thought to increase the risk of transmitting infection. |
| Monitor serial chest x-rays, ABGs, pulse oximetry readings. | Follows progress and effects of disease process/therapeutic regimen, and facilitates necessary alterations in therapy. |
| Assist with bronchoscopy/thoracentesis, if indicated. | Occasionally needed to remove mucous plugs, drain purulent secretions, and/or prevent atelectasis. |
Impaired Gas Exchange
Nursing Diagnosis: Gas Exchange, impaired
May be related to
- Alveolar-capillary membrane changes (inflammatory effects)
- Altered oxygen-carrying capacity of blood/release at cellular level (fever, shifting oxyhemoglobin curve)
- Altered delivery of oxygen (hypoventilation)
Possibly evidenced by
- Dyspnea, cyanosis
- Tachycardia
- Restlessness/changes in mentation
- Hypoxia
Desired Outcomes
- Demonstrate improved ventilation and oxygenation of tissues by ABGs within patient’s acceptable range and absence of symptoms of respiratory distress.
- Participate in actions to maximize oxygenation.
| Nursing Interventions | Rationale |
| Assess respiratory rate, depth, and ease. | Manifestations of respiratory distress are dependent on/and indicative of the degree of lung involvement and underlying general health status. |
| Observe color of skin, mucous membranes, and nailbeds, noting presence of peripheral cyanosis (nailbeds) or central cyanosis (circumoral). | Cyanosis of nailbeds may represent vasoconstriction or the body’s response to fever/chills; however, cyanosis of earlobes, mucous membranes, and skin around the mouth (“warm membranes”) is indicative of systemic hypoxemia. |
| Assess mental status. | Restlessness, irritation, confusion, and somnolence may reflect hypoxemia/ decreased cerebral oxygenation. |
| Monitor heart rate/rhythm. | Tachycardia is usually present as a result of fever/dehydration but may represent a response to hypoxemia. |
| Monitor body temperature, as indicated. Assist with comfort measures to reduce fever and chills, e.g., addition/removal of bedcovers, comfortable room temperature, tepid or cool water sponge bath. | High fever (common in bacterial pneumonia and influenza) greatly increases metabolic demands and oxygen consumption and alters cellular oxygenation. |
| Maintain bedrest. Encourage use of relaxation techniques and diversional activities. | Prevents overexhaustion and reduces oxygen consumption/demands to facilitate resolution of infection. |
| Elevate head and encourage frequent position changes, deep breathing, and effective coughing. | These measures promote maximal inspiration, enhance expectoration of secretions to improve ventilation. |
| Assess level of anxiety. Encourage verbalization of concerns/feelings. Answer questions honestly. Visit frequently, arrange for SO/visitors to stay with patient as indicated. | Anxiety is a manifestation of psychological concerns and physiological responses to hypoxia. Providing reassurance and enhancing sense of security can reduce the psychological component, thereby decreasing oxygen demand and adverse physiological responses. |
| Observe for deterioration in condition, noting hypotension, copious amounts of pink/bloody sputum, pallor, cyanosis, change in level of consciousness, severe dyspnea, restlessness. | Shock and pulmonary edema are the most common causes of death in pneumonia and require immediate medical intervention. |
| Monitor ABGs, pulse oximetry. | Follows progress of disease process and facilitates alterations in pulmonary therapy. |
| Administer oxygen therapy by appropriate means, e.g., nasal prongs, mask, Venturi mask. | The purpose of oxygen therapy is to maintain Pao2 above 60 mm Hg. Oxygen is administered by the method that provides appropriate delivery within the patient’s tolerance. |
Risk for Deficient Fluid Volume
Nursing Diagnosis: Risk for Deficient Fluid Volume
Risk factors may include
- Excessive fluid loss (fever, profuse diaphoresis, mouth breathing/hyperventilation, vomiting)
- Decreased oral intake
Desired Outcomes
- Demonstrate fluid balance evidenced by individually appropriate parameters, e.g., moist mucous membranes, good skin turgor, prompt capillary refill, stable vital signs.
| Nursing Interventions | Rationale |
| Assess vital sign changes, e.g., increased temperature/prolonged fever, tachycardia, orthostatic hypotension. | Elevated temperature/prolonged fever increases metabolic rate and fluid loss through evaporation. Orthostatic BP changes and increasing tachycardia may indicate systemic fluid deficit. |
| Assess skin turgor, moisture of mucous membranes (lips, tongue). | Indirect indicators of adequacy of fluid volume, although oral mucous membranes may be dry because of mouth breathing and supplemental oxygen. |
| Note reports of nausea/vomiting. | Presence of these symptoms reduces oral intake. |
| Monitor intake and output (I&O), noting color, character of urine. Calculate fluid balance. Be aware of insensible losses. Weigh as indicated. | Provides information about adequacy of fluid volume and replacement needs. |
| Force fluids to at least 3000 mL/day or as individually appropriate. | Meets basic fluid needs, reducing risk of dehydration |
| Administer medications as indicated, e.g., antipyretics, antiemetics. | Useful in reducing fluid losses. |
| Provide supplemental IV fluids as necessary. | In presence of reduced intake/excessive loss, use of parenteral route may correct/prevent deficiency. |
| Administer medications as indicated, e.g., antipyretics, antiemetics. | Useful in reducing fluid losses. |
| Provide supplemental IV fluids as necessary. | In presence of reduced intake/excessive loss, use of parenteral route may correct/prevent deficiency. |
Imbalanced Nutrition
Nursing Diagnosis: Risk for Imbalanced Nutrition Less Than Body Requirements
Risk factors may include
- Increased metabolic needs secondary to fever and infectious process
- Anorexia associated with bacterial toxins, the odor and taste of sputum, and certain aerosol treatments
- Abdominal distension/gas associated with swallowing air during dyspneic episodes
Desired Outcomes
- Demonstrate increased appetite.
- Maintain/regain desired body weight.
| Nursing Interventions | Rationale |
| Identify factors that are contributing to nausea/vomiting, e.g., copious sputum, aerosol treatments, severe dyspnea, pain. | Choice of interventions depends on the underlying cause of the problem. |
| Provide covered container for sputum and remove at frequent intervals. Assist with/encourage oral hygiene after emesis, after aerosol and postural drainage treatments, and before meals. | Eliminates noxious sights, tastes, smells from the patient environment and can reduce nausea. |
| Schedule respiratory treatments at least 1 hr before meals. | Reduces effects of nausea associated with these treatments. |
| Auscultate for bowel sounds. Observe/palpate for abdominal distension. | Bowel sounds may be diminished/absent if the infectious process is severe/prolonged. Abdominal distension may occur as a result of air swallowing or reflect the influence of bacterial toxins on the gastrointestinal (GI) tract. |
| Provide small, frequent meals, including dry foods (toast, crackers) and/or foods that are appealing to patient. | These measures may enhance intake even though appetite may be slow to return. |
| Evaluate general nutritional state, obtain baseline weight. | Presence of chronic conditions (e.g., COPD or alcoholism) or financial limitations can contribute to malnutrition, lowered resistance to infection, and/or delayed response to therapy. |
Acute Pain
Nursing Diagnosis: Pain, acute
May be related to
- Inflammation of lung parenchyma
- Cellular reactions to circulating toxins
- Persistent coughing
Possibly evidenced by
- Reports of pleuritic chest pain, headache, muscle/joint pain
- Guarding of affected area
- Distraction behaviors, restlessness
Desired Outcomes
- Verbalize relief/control of pain.
- Demonstrate relaxed manner, resting/sleeping and engaging in activity appropriately.
| Nursing Interventions | Rationale |
| Determine pain characteristics, e.g., sharp, constant, stabbing. Investigate changes in character/location/intensity of pain. | Chest pain, usually present to some degree with pneumonia, may also herald the onset of complications of pneumonia, such as pericarditis and endocarditis. |
| Monitor vital signs. | Changes in heart rate or BP may indicate that patient is experiencing pain, especially when other reasons for changes in vital signs have been ruled out. |
| Provide comfort measures, e.g., back rubs, change of position, quiet music or conversation. Encourage use of relaxation/breathing exercises. | Nonanalgesic measures administered with a gentle touch can lessen discomfort and augment therapeutic effects of analgesics. Patient involvement in pain control measures promotes independence and enhances sense of well-being. |
| Offer frequent oral hygiene. | Mouth breathing and oxygen therapy can irritate and dry out mucous membranes, potentiating general discomfort. |
| Instruct and assist patient in chest splinting techniques during coughing episodes. | Aids in control of chest discomfort while enhancing effectiveness of cough effort. |
| Administer analgesics and antitussives as indicated. | These medications may be used to suppress nonproductive/paroxysmal cough or reduce excess mucus, thereby enhancing general comfort/rest. |
Activity Intolerance
Nursing Diagnosis: Activity intolerance
May be related to
- Imbalance between oxygen supply and demand
- General weakness
- Exhaustion associated with interruption in usual sleep pattern because of discomfort, excessive coughing, and dyspnea
Possibly evidenced by
- Verbal reports of weakness, fatigue, exhaustion
- Exertional dyspnea, tachypnea
- Tachycardia in response to activity
- Development/worsening of pallor/cyanosis
Desired Outcomes
- Report/demonstrate a measurable increase in tolerance to activity with absence of dyspnea and excessive fatigue, and vital signs within patient’s acceptable range.
| Nursing Interventions | Rationale |
| Evaluate patient’s response to activity. Note reports of dyspnea, increased weakness/fatigue, and changes in vital signs during and after activities. | Establishes patient’s capabilities/needs and facilitates choice of interventions. |
| Provide a quiet environment and limit visitors during acute phase as indicated. Encourage use of stress management and diversional activities as appropriate. | Reduces stress and excess stimulation, promoting rest |
| Explain importance of rest in treatment plan and necessity for balancing activities with rest. | Bedrest is maintained during acute phase to decrease metabolic demands, thus conserving energy for healing. Activity restrictions thereafter are determined by individual patient response to activity and resolution of respiratory insufficiency. |
| Assist patient to assume comfortable position for rest/sleep. | Patient may be comfortable with head of bed elevated, sleeping in a chair, or leaning forward on overbed table with pillow support. |
| Assist with self-care activities as necessary. Provide for progressive increase in activities during recovery phase. and demand. | Minimizes exhaustion and helps balance oxygen supply and demand. |
Risk for Infection
Nursing Diagnosis: Risk for [Spread] of Infection
Risk factors may include
- Inadequate primary defenses (decreased ciliary action, stasis of respiratory secretions)
- Inadequate secondary defenses (presence of existing infection, immunosuppression), chronic disease, malnutrition
Desired Outcomes
- Achieve timely resolution of current infection without complications.
- Identify interventions to prevent/reduce risk/spread of/secondary infection.
| Nursing Interventions | Rationale |
| Monitor vital signs closely, especially during initiation of therapy. | During this period of time, potentially fatal complications (hypotension/shock) may develop. |
| Instruct patient concerning the disposition of secretions (e.g., raising and expectorating versus swallowing) and reporting changes in color, amount, odor of secretions. | Although patient may find expectoration offensive and attempt to limit or avoid it, it is essential that sputum be disposed of in a safe manner. Changes in characteristics of sputum reflect resolution of pneumonia or development of secondary infection. |
| Demonstrate/encourage good handwashing technique. | Effective means of reducing spread or acquisition of infection. |
| Change position frequently and provide good pulmonary toilet. | Promotes expectoration, clearing of infection. |
| Limit visitors as indicated. | Reduces likelihood of exposure to other infectious pathogens. |
| Institute isolation precautions as individually appropriate. | Dependent on type of infection, response to antibiotics, patient’s general health, and development of complications, isolation techniques may be desired to prevent spread/protect patient from other infectious processes. |
| Encourage adequate rest balanced with moderate activity. Promote adequate nutritional intake. | Facilitates healing process and enhances natural resistance. |
| Monitor effectiveness of antimicrobial therapy. | Signs of improvement in condition should occur within 24–48 hr. |
| Investigate sudden changes/deterioration in condition, such as increasing chest pain, extra heart sounds, altered sensorium, recurring fever, changes in sputum characteristics. | Delayed recovery or increase in severity of symptoms suggests resistance to antibiotics or secondary infection. Complications affecting any/all organ systems include lung abscess/empyema, bacteremia, pericarditis/endocarditis, meningitis/encephalitis, and superinfections. |
| Prepare for/assist with diagnostic studies as indicated. | Fiberoptic bronchoscopy (FOB) may be done in patients who do not respond rapidly (within 1–3 days) to antimicrobial therapy to clarify diagnosis and therapy needs. |
Deficient Knowledge
Nursing Diagnosis: Deficient Knowledge regarding condition, treatment, self-care, and discharge needs
May be related to
- Lack of exposure
- Misinterpretation of information
- Altered recall
Possibly evidenced by
- Requests for information; statement of misconception
- Failure to improve/recurrence
Desired Outcomes
- Verbalize understanding of condition, disease process, and prognosis.
- Verbalize understanding of therapeutic regimen.
- Initiate necessary lifestyle changes.
- Participate in treatment program.
| Nursing Interventions | Rationale |
| Review normal lung function, pathology of condition. | Promotes understanding of current situation and importance of cooperating with treatment regimen. |
| Discuss debilitating aspects of disease, length of convalescence, and recovery expectations. Identify self-care and homemaker needs/resources. | Information can enhance coping and help reduce anxiety and excessive concern. Respiratory symptoms may be slow to resolve, and fatigue and weakness can persist for an extended period. These factors may be associated with depression and the need for various forms of support and assistance. |
| Provide information in written and verbal form. | Fatigue and depression can affect ability to assimilate information/follow medical regimen. |
| Stress importance of continuing effective coughing/deep-breathing exercises. | During initial 6–8 wk after discharge, patient is at greatest risk for recurrence of pneumonia. |
| Emphasize necessity for continuing antibiotic therapy for prescribed period. | Early discontinuation of antibiotics may result in failure to completely resolve infectious process |
| Review importance of cessation of smoking. | Smoking destroys tracheobronchial ciliary action, irritates bronchial mucosa, and inhibits alveolar macrophages, compromising body’s natural defense against infection. |
| Outline steps to enhance general health and well-being, e.g., balanced rest and activity, well-rounded diet, avoidance of crowds during cold/flu season and persons with URIs. | Increases natural defenses/immunity, limits exposure to pathogens. |
| Stress importance of continuing medical follow-up and obtaining vaccinations/immunizations as appropriate. | May prevent recurrence of pneumonia and/or related complications. |
| Identify signs/symptoms requiring notification of healthcare provider, e.g., increasing dyspnea, chest pain, prolonged fatigue, weight loss, fever/chills, persistence of productive cough, changes in mentation. | Prompt evaluation and timely intervention may prevent/minimize complications. |
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